Provider Demographics
NPI:1770961914
Name:INTEGRATED PREMIER GROUP SPECIALTY, LLC
Entity type:Organization
Organization Name:INTEGRATED PREMIER GROUP SPECIALTY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:FERAS
Authorized Official - Middle Name:
Authorized Official - Last Name:ALDAOUD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-718-0568
Mailing Address - Street 1:2075 S COTTONWOOD DR
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282-3040
Mailing Address - Country:US
Mailing Address - Phone:480-718-0568
Mailing Address - Fax:480-307-6676
Practice Address - Street 1:2075 S COTTONWOOD DR
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-3040
Practice Address - Country:US
Practice Address - Phone:480-718-0568
Practice Address - Fax:480-307-6676
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-07
Last Update Date:2020-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
213E00000X, 208600000X, 103TF0000X, 104100000X, 207RG0300X, 207R00000X
AZ18871103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamilyGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ208912Medicaid